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Time Out

The New Physician May-June 2001
Many medical graduates find adventure, extracurricular experience
during time off between school and residency.



Dr. Alex Yang has a decision to make tonight: Olympic figure skating or ice hockey? At 7 p.m. he’s parked on the couch, talking on the phone and discussing the dilemma with his roommate. (Yang is voting for figure skating while his roommate is trying to change the channel to hockey.) By the end of the phone conversation it’s Yang 1, Roommate 0—Michelle Kwan is gliding across the television screen.


Yang knows he’s not like other M.D.s fresh out of medical school. Instead of gazing at the television, he could be watching patients multiply in the ER waiting room at the tail end of a 36-hour shift. The decisions that night could be a little more important than selecting figure skating or ice hockey.


Instead, Yang is putting all that on hold while he takes some time off between medical school and residency. He spends his days working for the business-strategy consulting firm McKinsey & Company in Los Angeles, where he’s working on a five- to 10-year business plan for a medical device manufacturer posting $10 billion in annual revenue. Don’t get him wrong, though. His daily decisions—which affect the actions of corporate executives—aren’t meaningless, but in “the worst case, nobody’s going to die,” he says. “It matters to some people, but at the end of the day, I’m not going to kill anybody with the decisions I make.”


Yang’s not alone. Each year about 400 medical school graduates—or 2.6 percent of them—leave the beaten path to residency for seemingly greener pastures. The reasons they give are varied: Some, like Yang, want to test the waters of corporate life, while others need some time for travel, volunteer work or even to earn another degree. Some come back to clinical medicine, while others never do. But no matter what they’re doing, most of these medical graduates learn that a little time out can provide the experience of a lifetime.


BROADENING YOUR HORIZONS


Yang, who also holds an M.B.A. and says he intends to go on to an emergency medicine residency in a few years, says he took on the consultant’s life after medical school because he knew he wouldn’t be able to take an opportunity like this after residency. “When you finish residency, it’s time to work now,” he says.


He says new physicians who go right to residency are often plagued with yearnings to have experiences different from day-to-day clinical medicine. “A lot of residents say, ‘If I had done this, or if I had done that….’ I won’t be saying that because I did ‘that,’” he says of his break. “Med students should know that they have a much broader array of options than they think they have.”


Dr. Amy Wagner certainly saw broader options than entering residency training right away. An internship in Belize during her fourth year of medical school piqued her interest in caring for underserved populations around the world. So as she entered the Match process to gain acceptance into a surgery residency, Wagner began to investigate clinical volunteer opportunities in Africa. While most organizations disregarded her because of her lack of a medical license, an American-born physician who operates a small surgical practice in Cameroon accepted her offer. And so, a few weeks after graduating from the Medical College of Wisconsin (MCW) last June, Wagner was off to Africa.


She began her work in a 200-bed hospital by rounding daily on the 50 to 70 patients for whom she and the American surgeon cared. “But it’s much easier, because there’s no paperwork,” she says. “And the only notes were the ones I would make for myself to remind myself.” It wasn’t long before Wagner was doing her own cesarean sections and appendectomies. “It was pretty scary,” she says, adding that she performed her first solo cesarean section after observing one and conducting another under the surgeon’s supervision. “She said, ‘You did so well with the last one, you just go ahead and do it,’” Wagner says of her mentor, sounding a little amazed at the liberty she was given in the operating room.


She says she decided to take advantage of the African opportunity because she knew that after seven years of surgical residency, she might have family and work commitments that would preclude her from working overseas. “Now’s the time to do this,” she says.


And while “I would never, ever regret what I did—it taught me so much about myself and what I value,” she says she is now craving the formal education a U.S. surgical residency can provide. She left Cameroon in December to interview for the Match and will be headed to Virginia Mason Hospital in Seattle later this summer. In the meantime, she is spending the months before her residency back in Cameroon, soaking up all that Third World medicine has to offer. “I’m dreading residency in that it’s going to be long and awful, but for me [that way of learning] just clicks.”


Like Wagner, Dr. P. Travis Harker also fully intended to go on to residency when he took some time off after graduating from Ohio State University College of Medicine in 2001. Having decided after his third year of medical school that he wanted a break before residency, he pursued several opportunities for his time away from the hospital, finally selecting a research fellowship at the Office of Disease Prevention and Health Promotion (ODPHP) at the federal Department of Health and Human Services in Washington, D.C. “I decided I wanted another experience in public health,” he says. “And Healthy People 2010 was a great opportunity to get my hands dirty in public health.”


Like Wagner and Yang, Harker says the time was right to take some time off from clinical medicine. “This was a good time for me to recharge my batteries and broaden my horizons,” he says. “As a med student, you don’t have a lot of time to reflect on things, and now I have an 8 to 5 schedule, and I come home, and I don’t have to think about work.”


SHOULD I STAY OR SHOULD I GO?


All of these young physicians agree that a year or two off after medical school can help you sort out what you want to do with your newly earned degree, but be forewarned: They also agree that time away from the hospital can make you never want to go back. It’s something Yang says he struggles with a great deal, especially since, unlike Harker and Wagner, there is no set end date for his consulting job. “The longer you’re here, the harder it is to go back,” he says. And who could blame him? Working 60 hours a week for more money than the average emergency attending makes, getting to influence powerful corporate executives and their companies, sleeping regular hours—what’s not to like about his job? “Is there a chance that I won’t go back? Yeah,” he admits. But he says at least he knows that if he does choose to do a residency, it will be the right decision. “I would just have much better perspective on what I’m doing. This [time off] would just sort of ground you. You would know why you were doing what you were doing.”


Yang says he sometimes misses medicine, so he volunteers his time in local emergency rooms. “I get reminded of what my life will be like,” he says. For all of the stark differences between corporate consulting and medicine, there is much that’s the same, he says. “I do enjoy medicine—seeing patients, the sort of thought processes that goes with diagnosing.” It’s a process similar to his work in the corporate world: He sees an ailing company and then figures out how best to leverage its resources to fix the problem. “I think the training you get from medicine prepares you for a lot of jobs in corporate business.”


Yang’s concerns about never getting back to medicine are certainly real. It’s not difficult to find physicians who don’t practice medicine, despite dedicating four years and countless loans to obtaining an M.D. or a D.O.


Dr. David Shih left his internal medicine residency at Johns Hopkins University just four months into the program, and he says he doesn’t see himself going back. “In the end, I decided I was sacrificing my relationships with my family and my girlfriend, my health.… It was a difficult decision. It’s really hard to let go of all that blood, sweat and tears—and money. Every now and then I still feel like I’ve really screwed up.”


Far from “screwing up,” Shih put his medical degree and a longtime interest in radio to work at a San Francisco public radio station where he’s spent the last year as the outreach manager for a brief, daily health program. He says his former life is always in the back of his mind, but “I guess I just decided that life is just too short. You can’t sacrifice time spent with loved ones. You can’t sacrifice your health.”


Yang says he respects people like Shih and others who never went on to finish a residency. “I wouldn’t say they’ve left medicine. They’re just using their skills differently,” he says.


DEALING WITH THE DIRECTORS


For those who do decide to go on to residency, there are always concerns about how program directors are going to view your soul-searching, see-the-world break from medical training. You know how hard it is to interview under normal circumstances? Well, try it when there’s an educational gap on your C.V.


Wagner says she was nervous about explaining her African surgical experience to U.S. residency directors. She says she knows that as a woman looking to enter a male-dominated field, she might come off looking “flaky.” So she incorporated the story into her personal statement. And to her surprise, about 50 percent of the programs in which she was interested were intrigued, even excited by what she did during her year off. However, “it’s definitely two extremes,” she says.


Wagner, who has had the unusual experience of going through the Match twice because of her last-minute decision to go to Cameroon, says one program that had been positive about her the first time around didn’t even invite her for an interview this year. “Definitely there were some programs who said, ‘Why do this now? Are you crazy?’ But those aren’t really programs I want to work for anyway. I definitely think that doing something like this helps me find a place that fits better.”


Because he arranged his residency at Dartmouth outside the Match last August, Harker’s future program was aware of his activities during his time off. “They see [my ODPHP work] as a benefit. They appreciate the prevention component,” he says, adding he knows his program’s attendings will be looking to him to add to the education of his fellow residents because of his unique experience. For example, while discussing a diabetic patient on rounds, Harker says he might be able to incorporate some information about the disease from the public health perspective, which could enhance the residents’ learning that day.


Of course, “if you take a year off and you go out to Colorado and be a ski bum, I think that sets off some red flags,” Harker says. “But if you work in health [-related fields], that says that you may [someday] be a leader in health policy, and programs are always looking for that.”


Program directors would agree. Dr. Douglas Miller, the pathology residency director at New York University Medical Center, says any time off on a person’s C.V. is a warning sign, but it all comes down to why the hole is there. “Did they take a year off because they were in drug rehab? Did they take a year off because they were under psychiatric care? And if it turns out that someone had enough money to travel the world, or they wanted to take time to do research or volunteer somewhere else, some of those efforts are quite laudable,” he says. “If everything else went well, if their grades were good, then I don’t see a problem.”


Miller would even encourage a little break between medical school and residency for a student struggling with what direction to take in medicine. He says taking time out then wouldn’t necessarily haunt a physician’s career the way a break or a program switch during residency would.


Yang, who like Wagner was in the middle of the Match when he decided to take the McKinsey job, says he contacted all the residencies he interviewed with to explain why they should no longer consider him. About 60 percent of them were positive, including his top choice program, which he says was receptive to his plan and whose program directors continue to welcome him when he drops by for a visit. Still, he says he gets “a lot of bimodal responses—people [who] think I’m either crazy and stupid or people who think I’m crazy and smart.” He says anyone considering a path like his will need to be prepared to explain the decision. “[Program directors] will want to know why you took time off, and the only acceptable reason across the board is research. ‘I wanted to take some time off and join Greenpeace’—that’s not going to fly with residency directors,” he says.


MAKING THE MOVE


Just a hunch, but the Greenpeace plan is also probably not going to fly with your dean when you tell her that come graduation, you’re off to a tropical island. And no matter what your plans are, telling your medical school faculty can be the most difficult part of any break. Wagner began by talking to her director of surgery at MCW. “It was totally the most frightening thing I ever had to do,” she says. “The chair of surgery doesn’t have the reputation as the most open-minded guy. I was frightened and pretended I was Madeline Albright… because who can say no to her? And it worked! He was really supportive.”


That was not true of all of her professors, though. “It was a difficult decision just because of the response of my mentors in med school. It was really hard for me to go against the advice of people who I respected.”


The decision for Yang was so difficult that he put it off until the last possible moment he could withdraw from the Match and not be blacklisted the second time around. He says in the more conservative, research-oriented atmosphere at the University of Chicago, where he went to medical school, he found few faculty who supported his decision. But talking to people can help. Many physicians who have taken a break or left medicine altogether say they began by speaking to as many nonclinical physicians as possible just to get a better idea of what options are out there for M.D.s and D.O.s.


And no matter how difficult the decision, it really needs to be made late during the third year of medical school. Wagner says early in her fourth year, when she began looking for an alternative to residency, was really too late. “In hindsight, I had no idea how long it would take to find someone who would take me,” she says. “In my case, I had to be very determined and set the whole thing up,” even applying for grants and corporate funding to pay for the experience.


Granted, organizing a trip such as Wagner’s is more time-consuming than applying for a job opening like Yang and Harker did. But if you enter the Match while concurrently conducting a job search that would require a year or two off before starting a residency, be aware that the cutoff date to legally withdraw from the Match process is in February of your fourth year of medical school. A sponsoring medical school must also endorse withdrawals, so it’s good to get your dean’s approval for your plans early.


Harker says the decision to take time out from medical education really comes down to determining what you want to get out of your learning experience and where you see your career going. “You really have to think long and hard, because you really can get on the wrong track,” he says, adding that it would be easy to feel that the time off netted nothing more than a year of wasted time.


But for those who plan it well, some time off can give you a unique learning experience and still provide you with a little time for relaxation that residency doesn’t offer. Just ask Alex Yang. But you might want to wait—he’s a little tied up right now: The bobsled competition is about to begin.
Jennifer Zeigler is a senior writer with The New Physician.